DOCTORS TECHNOLOGY OFFICE VIRTUAL CARE TOOLKIT

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VIRTUAL CARE

Table of Contents

Summary ...... 2 Essentials: Getting Started with Virtual Care...... 2 Workflow: A Step-by-Step Approach ...... 3 Equipment Essentials and Testing ...... 6 Virtual Care Practical Tips ...... 7 Billing Guide ...... 8 Tools ...... 11 Privacy and Security Safeguards ...... 14 Communicating With Your ...... 15 Consent Statements ...... 17 Policies and Guidelines ...... 18 Frequently Asked Questions (FAQs) ...... 19 DTO Virtual Care Enablement Program ...... 19

Summary This document is intended to provide at the very least, the foundational information needed to enable a physician/clinic to get up and running with offering virtual care services within a relatively short time frame.

Doctors Technology Office (DTO) is here to support you. Please reach out if you have questions or would like support from a peer mentor. 604 638-5841 [email protected] www.doctorsofbc.ca/DTO

Essentials: Getting Started with Virtual Care ▪ Phone calls can be used for virtual care Obtain patient email addresses and mobile numbers ▪ NOTE: ▪ Validate identity and discuss risks/limitations of virtual care Providing virtual care can be Inform and educate patients ▪ as simple as a phone call, ▪ Review the billing and also includes video ▪ Select an appropriate virtual care tool visits and secure ▪ Start providing virtual care visits messaging.

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Workflow: A Step-by-Step Approach Clinic Notes 1. Engaging the team

▪ Staff and MOAs are key to success. Consider internal meetings to discuss the benefits of video visits, changes, workflow, and responsibilities. ▪ Ensure you have a process to communicate with the team remotely if needed. ▪ Review step-by-step approach to identify gaps, needs and barriers. Discuss possible improvements.

2. Obtaining and recording patient email addresses and mobile numbers ▪ Email addresses can be used for promoting new virtual care services to groups of patients, as well as sending the virtual care visit link to an individual patient. ▪ Phone numbers are useful for communicating with a patient if there are any issues with the virtual care visit, or to ensure they are ready for their visit. ▪ Consider how minimal contact information (e.g. name, email) can be exported from the EMR for using in other electronic tools (e.g. broadcast communication tools).

3. Establishing communication channels with patients ▪ Consider setting up a clinic email address to communicate with patients. Decide if you allow patients to email the clinic back. ▪ Investigate technology tools for communicating with patients (e.g. clinic website, Pathways).

4. Informing patients about the new virtual care service

▪ Develop a plan to promote virtual care to your patients and other information that will benefit them. ▪ Create message templates to streamline communication.

5. Patient handouts and resources ▪ Consider how to support your patients, and review available resources (e.g. booking virtual care visits, technical tips, patient etiquette). ▪ For examples, see the Patient Communication section in this Toolkit.

6. Obtaining and recording patient consent ▪ Select the format for capturing patient consent. ▪ Develop a standard process for collecting consent, documenting in the patient chart, and keeping track of who has/has not provided consent. ▪ See the Patient Consent section below for more details, templates and examples.

7. Selecting suitable patients ▪ Review patient panel to understand appointment types and patient groups that are suitable for in-person, telephone, and video visits. ▪ Review your schedule to identify opportunities for virtual care visits.

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Clinic Notes 8. Updating appointment schedule ▪ Consider specific days and time slots for virtual care visits and adjusting the current schedule. ▪ Consider creating appointment types for virtual care visits.

9. Booking virtual care visits ▪ Consider how patients can book virtual care visits. ▪ Consider staff triaging the booking of patients visits for video, phone, or in-person. ▪ Consider how you invite patients to the virtual appointment (e.g. create an appointment invitation template).

10. Selecting video conferencing tool ▪ Investigate what video conferencing tool is the best fit for your clinic. Consider features like a virtual waiting room, sharing screen, sharing documents, and chat option. ▪ Consider the cost and what support and resources are available.

11. Setting up the workspace

▪ Essential items include: webcam, microphone, and speaker. ▪ Consider the placement of EMR screen vs. placement of video screen and the best way for accessing patient chart during a video visit. ▪ Consider the space that the patient will view during a virtual care visit. ▪ Consider virtual communication etiquette.

12. Patient preparation for a virtual care visit ▪ Consider the workflow to ensure the patient is ready for their virtual care visit (e.g. contacting the patient ahead of time). ▪ Consider the supporting role of the MOA (e.g. communicating with waiting patients, troubleshooting).

13. Back-up plan for the virtual care visit ▪ Consider having a back-up plan in case there are issues with a virtual care visit (e.g. switching to telephone, scheduling another virtual or in-person visit).

14. Virtual care visit notes ▪ Consider having a standard method for recording that the visit was conducted over video or telephone. Consider creating a note template.

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Clinic Notes 15. Sending and receiving documents If working away from the clinic, consider how to transfer / fax documents (e.g. prescriptions, lab and imaging requisitions, forms, notes, and images). ▪ Consider how to e-fax documents. ▪ Consider how to add signatures to documents within or outside of the EMR. ▪ Consider how to provide electronic documents to patients (e.g. via email or a patient portal). ▪ Consider how to receive documents from patients and link these to the patient chart (e.g. patient portal). ▪ Consider MOA as a supporting role in the workflow. ▪ Ensure the privacy of information is protected when sharing documents. ▪ For information on e-fax workflows when working from home/remotely, please refer to DTO Guide to e-faxing when working remotely.

16. Ending a virtual care visit ▪ Consider the workflow for arranging a follow-up visit and for providing the instructions to the patient. ▪ Consider how you communicate the end of the virtual care visit (e.g. “We're nearing the end of the visit, is there anything I can clarify for you?”, “Do you have any questions before we sign off?”)

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Equipment Essentials and Testing Note: During the Covid-19 pandemic, MSP has approved use of the telephone, without video, for provision of services which can be billed using fees.

Equipment essentials For a virtual care visit, the device you are using (e.g. computer, laptop, tablet, or smart phone) should be equipped with the following accessories:

▪ Webcam ▪ Most devices have webcams built in so make sure to test to verify the quality of the image. If required, consider investing in a good quality camera which can also include a microphone (about $100). 1 ▪ Features to consider: ▪ HD resolution 1920x1080 pixels (no higher needed), Minimum 30 frames per second, Automatic low light correction, Noise cancellation system and integrated microphone, and Lens cover for when not in use (privacy). ▪ Speaker/Headphones ▪ If required, ideally invest in good-quality speakers or earphones/headphones as good audio can help you hear your patients properly. While earphones/headphones are visibly intrusive, they prevent the patient being overheard by other people, and adds privacy in physician work environments that have substandard sound insulation.1 ▪ Microphone ▪ Can be built into webcams and headphones.

Testing your equipment It is important to test the hardware prior to a virtual care visit to ensure that the webcam, microphone and speaker are all working and to become familiar with how to adjust the settings.

Testing the speed of your internet connection We recommend that you run an online speed test from the same room where you will have your video consults to find out the internet speed. Use the equipment you are planning to use for the most accurate test. You can use the site (https://www.speedtest.net/ Ideal is ~20Mbps to 50Mbps or more).

Secure USB Drive If you cannot save and edit third-party forms through your electronic (EMR), it is recommended that you use secure electronic storage for documents that contain private patient information and deleting the file once the purpose has been completed (i.e. patient submits a signed form, once uploaded securely to EMR, delete from device). Consider using a USB key that automatically encrypts the data it stores (about $50) and secure it with a strong password1 (See DTO Password Management Guide (PDF) for password best practices).

1 Information from the Canadian Medical Association, which can be accessed here.

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Virtual Care Practical Tips

Tools ▪ Practice, practice, practice with the virtual care tool to become more comfortable with the technology and to identify areas where there may be challenges. Practice with your MOAs and your friends and family. Ensure your MOAs are very familiar with the tool as they can help support patients to troubleshoot issues. ▪ Virtual backgrounds – some tools allow the user to add a virtual background. This is not recommended as this uses the processor of the device and could reduce the quality of the virtual care visit.

Optimize the video environment ▪ Webcam/Video camera ▪ If possible, set up the video camera right above the patient's image. This view is the easiest way to promote the appearance of eye contact. ▪ Two monitors can give you more screen space. Consider displaying the EMR window on one monitor and the virtual video window on the other monitor. ▪ If using two monitors, the video camera should be above the monitor which your eyes are focused on most.

Patients ▪ Technology challenges – Many people (especially elderly) may have trouble finding the appointment link in the invitation email or find the technology difficult to start using. ▪ Try and arrange a more tech-savvy support person (such as a family member) to be in the room with the patient at the beginning of the visit to help get them set up. ▪ Be prepared to call the patient to walk through the problem they are having connecting to the tool. ▪ Don’t spend too long trying to fix a problem with the tool. Use a phone call if there are difficulties. ▪ Webcams – Remember, not everyone has a video camera or knows how to turn it on if they do have it. ▪ Family members – It is recommended that other family members do not stream video or have video conferences at the same time as the patient’s virtual care visit, this helps to improve the quality of the virtual care visit.

Network ▪ Bandwidth – Some areas of the province may not have the necessary bandwidth to support audio and video in the virtual tool. If you are getting a broken signal, try turning off the video at one, then both ends of the conversation. If the audio is still broken, switch to a phone call. ▪ Ethernet cable – If possible it is recommended to use an ethernet connection between the computer and the router as it is generally faster than a WiFi connection and provides greater reliability and security. ▪ Smart phone hotspot – You can use your smartphone’s hotspot feature if the internet isn’t working. However, please note that you will be using the data on your plan.

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Billing Guide

Note: For up-to-date billing codes, current changes and removal of any constraints, please see the DoBC website.

The following is effective immediately, with an end date to be determined by the Provincial Health Officer:

▪ The requirement that services provided and billed under telehealth fees must involve video technology has been changed to allow billing of telehealth fees for services provided by telephone. Therefore, if you conduct services via telephone you can bill the appropriate telehealth fee codes in your section’s Fee Guide. This includes services for all patients including COVID-19 patients. ▪ Consultations, office visits, and non-procedural interventions where there is no applicable telehealth fee may be claimed using the appropriate face-to-face fee and including a claim note record that the service was provided via video technology or telephone. ▪ The fee items cannot be interpreted without reference to the Preamble D.1. Telehealth Services in the MSC Payment Schedule. Please read the individual fee rules in the Doctors of BC Fee Guide or MSC Payment Schedule. If a telehealth service is interrupted for technical failure and not concluded, claim can be submitted under the appropriate miscellaneous code.

Services directly related to COVID-19 should include diagnostic code C19. Physicians should continue to use their professional judgement to determine whether use of virtual technology is clinically appropriate based on the circumstances of each patient. Details for billing purposes can be found here.

Effective May 1, 2020, the Business Cost Premium (BCP) will be temporarily expanded to apply to telehealth fee items, including phone and video communication with patients. This change ensures the BCP is paid during the COVID-19 pandemic, given these services would have normally been provided in person in physician’s offices. Click here for more information.

Commonly Used Telehealth Fee Codes

General Practitioner Telehealth Fees

Note: Effective June 1, 2020, Submission of fee codes 13037, 13017, 13038 and 13018 with dates of service on or after June 1 will be rejected.

NEW: Age-adjusted telehealth fee codes for visits, counselling and consultations done by phone or video will come into effect on June 1, 2020. These new fees have the same value as the in-person fee codes for similar patient encounters. Download a cheat sheet (from the BC Family Doctors) on the Telehealth Fee Codes effective June 1, 2020. ▪ These fee codes are for services delivered by phone or video. ▪ These fee codes should be used regardless of the physician’s location (home, office or Health Authority approved facility). ▪ Business Cost Premium (BCP) will apply to all of them. ▪ Retro payments will not be made for dates of service prior to June 1, 2020.

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▪ From March 16 – May 31, 2020, the same telehealth fee codes for visits, counselling and consultations done by phone or video are to be used for patients, regardless of age. (13037 and 13038 in most circumstances). From June 1 onwards, use the new fee codes for phone and video services.

GPSC - Initiated Virtual Care Fees Billing MSP Service Code Fee

G14076 $20.00 GP Patient Telephone Management Fee. 3

G14078 $7.00 GP Email/Text/Telephone Advice Relay.

3 Until further notice: Effective June 1, 2020, physicians providing medical services to patients by phone may use the age- adjusted telehealth fee codes instead of G14076.

General Practitioners - new time limited fees

Billing MSP Service Code Fee

T13706 $20.00 GP Delegated Patient Telehealth Management Fee (similar to G14076). 4

T13707 $7.00 GP Email/Text/Telephone Medical Advice Relay or ReRX Fee (similar to G14078). 4

T13708 $40.00 GP COVID-19 communication with specialist and/or allied care provider is a new fee. 4

4 Effective March 27, 2020. Further information on these new time limited fees is available here on the Doctors of BC website.

General Practitioners – Group Visits via Videoconferencing Billing MSP Service Code Fee

Telehealth GP in-office Group Counselling For groups of two or more patients – First full T13041 $86.94 hour

Telehealth GP in-office Group Counselling For groups of two or more patients – Second T13042 $43.50 hour, per ½ hour or major portion thereof

General Practitioner and Specialist Covid-19 Office Visit fees - new time limited fees

Billing MSP Service Code Fee

T13701 $50.00 Office Visit for COVID-19 with test. 7

T13702 $40.00 Office Visit for COVID-19 without test. 7

7For further information on these new time limited fees, please refer to the Doctors of BC website here.

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Specialists Telehealth Fees

Please refer to the MSC Payment Schedule or the Doctors of BC Fee Guide for the appropriate telehealth fees for your section. Where there is no existing telehealth fee, the face-to-face fee may be claimed with a claim note record that the service was provided via video technology or telephone. Billing MSP Service Code Fee

G10003 $24.05 Specialist Patient Management / Follow-up – per 15 minutes or portion thereof

G10006 $10.10 Specialist Email Patient Management / Follow-up

Specialists - new time limited fees Billing MSP Service Code Fee

T10000 $60.00 Urgent Specialist Advice on patient with previous visit/service Fee (similar to G10001). 5

T10009 $40.00 Non-urgent Specialist Advice on patient with previous visit/service Fee (similar to G10002). 5

T10007 $10.10 Specialist Email/Text/Telephone Medical Advice Relay or ReRX Fee is a new fee. 6

T10008 $60.00 Urgent Specialist COVID-19 Advice Fee (similar to G10001). 6

5 Effective April 15, 2020. Further information on these new time limited fees is available here on the Doctors of BC website. 6 Effective March 27, 2020. Further information on these new time limited fees is available here on the Doctors of BC website.

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Tools DTO is a neutral body and does not endorse or promote any solution or tool. Please contact DTO for guidance on privacy and security safeguards for implementing virtual care in your clinic.

There are several different technologies that can be used to deliver virtual care. The tools outlined below provide an overview of the most common types of tools being used by physicians.

Please reach out to DTO for support needs on choosing and implementing virtual care tools.

Virtual Care Tools ▪ Videoconferencing tools – videoconferencing tools for provider-to-patient communication and for group visits ▪ Secure messaging tools – secure email and secure text messaging ▪ Cloud-based phone tools – make/receive calls from outside the office on your smartphone and mask your outgoing phone number ▪ Video/audio remote interpreting – for language interpretation services ▪ Home Health Monitoring – for patient screening and/or monitoring for symptoms

EMR Vendors To find out more about the virtual care tools integrated into your EMR, please contact your EMR vendor for the most up-to-date information.

Tools to Broadcast Messages to Patients

Privacy Note: When using third party tools to communicate with patients, use discretion to only enter/upload minimal information that is essential to communicate with patients (e.g. patient name, phone number, and email address).

▪ Broadcast messages – to communicate to groups of patients with information about your virtual care services or clinic updates ▪ Voice messaging services – to provide ongoing communication to patients who call your clinic e-Faxing Tools For information on e-faxing, please refer to DTO’s Guide to e-faxing When Working Remotely.

Other Tools ▪ Document signing – to enable patients to electronically sign documents (e.g. patient consent) ▪ Remote access to clinic computers – we strongly recommend that you connect with your EMR Vendor, DTO, or your local IT for support with these tools

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Selecting a Virtual Care Tool This section is intended as a guide and covers only the most general guidelines when selecting a virtual care tool. Given that each practice and their specific needs are unique, there are some topics that have not been fully addressed. Please reach out to DTO for further questions, clarification or support on virtual care tools.

There are many different virtual care tools on the market that vary with respect to functionality, cost, customer support, privacy and security, and overall workflow and user interface.

Consider contacting your Division of Family Practice to get more information on any tools that have already been implemented in the community.

An initial step is to outline your practice’s unique needs and what specific workflows could benefit from adopting a virtual care tool.

Once you have defined your needs we recommend that you contact at least two to three vendors to discuss their tool in more detail. Below is a list of questions and considerations to help guide your discussions with the vendors.

Questions to Ask Vendors

Cost ▪ Inquire about pricing structure and licensing/subscription fees ▪ Ask about any additional costs related to training, data analytics, custom reporting, and customization Support ▪ What is the vendor support structure and how are issues handled? ▪ What is their preferred method for submitting issues e.g. email, phone or live chat messaging? Device Compatibility ▪ Does the physician or patient need to download any software or apps? & Supported ▪ What web browsers are supported? Browsers ▪ Is the tool compatible with both iOS and android? Demo ▪ Speak to your peers about their recommendations and experiences and ask to arrange a virtual demo of how they use the tool in their practice. If you would like to chat to a peer mentor, please reach out to DTO ▪ Ask vendors for a demo of their system and have them demo the features that are of particular importance to you References ▪ Ask for references that you can contact to get feedback and personal experience Free Trial / Free ▪ Does the vendor offer a free trial or free version of their tool? Version ▪ If the vendor offers a free version, ask for a feature comparison chart to see the differences with their paid versions

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Questions To Ask Vendors

Privacy & Security ▪ Request detailed information/documentation from vendors about the privacy and security measures that have been built into their tool. If you require more guidance and assistance around this specific topic, please reach out to DTO ▪ Ask the vendors to confirm if the transmission of data is encrypted. ▪ Do they store any information? If so, what information is stored? ▪ Ask about server location and if they have the option to host servers in Canada.

Many videoconferencing tools offer a variety of features and functions to improve workflow efficiency. You may want to consider some of the following features: General Features ▪ Waiting room ▪ Secure messaging feature (both in the waiting room and in the virtual care visit) ▪ File transfer (what types of files can be shared?) ▪ Screen sharing ▪ Group visits (multiple participants) Other Features ▪ EMR Integration ▪ Online booking (patient) ▪ Scheduling (provider) ▪ Appointment notifications/reminders ▪ Charting

Implementing a Virtual Care Tool Once I have chosen a virtual care tool what are the next steps?

This will vary from vendor to vendor and the tool you’ve chosen. Some tools require very little in terms of implementation while others offer customization in which case the vendor will work with you directly to document and apply your customization requirements. Ensure that you have a point of contact or an account manager dedicated to supporting you through the process of setting up your virtual care tool and addressing any technical issues that you may encounter. What is the timeline for implementing a virtual care tool?

The timeline will depend on the type of virtual care tool you have chosen, testing, any required customization, and training staff who will be accessing and using the virtual care tool.

Virtual Care Costs Do you have any information on the approximate costs for the various virtual care tools?

Pricing varies depending on a number of factors including practice size, number of users, customization, etc. Each vendor will have a different pricing structure and different plans to select from. You will need to contact the vendor directly for a personalized quote.

Tool Selection See section on Tools for guidance on assessing the appropriateness of virtual care tools. Last Updated: Feb 23, 2021 13 of 20 DTO - 321934

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Privacy and Security Safeguards Under the Patient & Care Team Digital Communications Policy, providers should make reasonable efforts to fulfill these minimum requirements prior to communicating electronically with patients or caregivers: ▪ Provide reasonable notification of risks (see Appendix A) ▪ Validate the patient’s identity before sharing personal health information (see Appendix B) ▪ Secure your devices & applications (See Appendix C)

Session Safeguards ▪ Always ensure the patient is ready to have a confidential conversation. When appropriate, start video session with clear introductions and confirming the patient’s identity. ▪ Conduct the video session in a private space in both yours and the patient’s location. Using a phone or other mobile device in public could compromise the patient’s confidentiality. During the session, check if the volume is set to an appropriate but discreet level. ▪ A patient may want to include a family member or caregiver during the video consult. If so, be aware of who is in the room with the patient. Establish the level of patient comfort and follow the same principles as with in-person visits. ▪ Do not leave connection unattended and/or set on automatic call answering. Once the session is over, all participants are expected to disconnect from the call immediately.

Technology Safeguards ▪ Refrain from using any unsecured public networks. When setting up a wireless connection in your clinic, use an adequate password that is shared only with authorized users. If you require assistance using your software on the Private Physician Network (PPN), contact DTO for support. ▪ All systems, applications, and devices should be behind a firewall with anti-virus/malware software installed. ▪ Updates and security patches should be applied as they are made available by the software vendor. Ensure the device used for videoconferencing is not obsolete and the most recent updates are always applied. ▪ All devices used for videoconferencing, and the sessions themselves, should be password-protected to prevent accidental configuration changes or hacking attempts. ▪ Avoid recording videoconference sessions containing personal or clinical information unless it is absolutely necessary. If a recording must be made, the best practice is to retain it as part of the clinical record. Implement security measures such as secure storage behind a firewall. When using personal, mobile and desktop devices, the best practice is to encrypt a device and use two-factor authentication for access. (Please reach out to [email protected] for support on how to do this). ▪ Disable cameras and microphones when not in use, either by disconnecting power, connection cables, and/or using lens coverage.

To further support private practice physicians, Doctors Technology Office (DTO) has created the Physician Office IT Security Guide, BC Physician Privacy Toolkit and other resources that are available through DTO’s website.

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Communicating With Your Patients

This section of the toolkit provides useful templates and tools that will help you notify patients that you are offering virtual care services and help them learn how to start accessing virtual care on their smart phone or computer.

Promoting Virtual Care in Your Clinic

1. Choose a date to start using virtual care in your clinic. 2. Let patients know that the service will be available by providing information on your website, via email, via posters (see below) in your clinic and by telling them in person. 3. Consider outlining the process of signing up for virtual care on your website, along with a list of the conditions that are eligible and excluded. 4. Train your staff on how to troubleshoot the most common technical issues related to virtual care so they can assist patients over the phone.

Patient Communication Templates & Resources ▪ Virtual Care for Patients – FAQ & Troubleshooting Tips - Information to help patients prepare for virtual care visits. Designed for clinics to share with their patients as a resource guide. ▪ Clinic Transition to Virtual Care Poster - Editable/printable poster (MS Word) for clinics to notify patients that they are providing some of their care and visits virtually, either over the phone or video. English | Arabic | Chinese (simplified) | French | Hindi | Korean | Farsi | Punjabi | Spanish ▪ Patient & Care Team Digital Communications Policy & Appendices – Refer to Appendix A-C for templates.

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Email Template example: Virtual Care - Introduction for Patients In order to expand our services and availability to patients, our clinic will be introducing virtual care visits as of [Date]. Patients will now be able to connect with their family doctor from the location of their choosing, using their smartphone or computer.

Check out the Virtual Care for Patients – FAQ & Troubleshooting Tips attached to this email for more information about how to access this new service. To sign up for a virtual care visit, refer to our [Website] for appointment availability and clinic hours. For questions or assistance with troubleshooting, please contact the clinic at [Clinic Phone] or [Email].

Email Signature Disclaimer example: when sending emails to patients Consider including the following disclaimer when sending emails to patients:

DISCLAIMER: Please note, we cannot guarantee the confidentiality of information transmitted through e-mail. Please be aware of this limitation when contacting us.

Email Template example: Virtual Care - Visit Email Invitation Note: Depending on the tool, clinics may opt to utilize a virtual waiting room model or to send set up scheduled virtual care sessions. The following template can be used as an email invitation for scheduled virtual care appointments.

This is a courtesy reminder of your virtual care appointment at [Name of Clinic]:

[Date & Time] [Virtual Care Meeting Link] [Teleconference Phone # and Meeting ID] [Application help link or clinic contact info]

Please ensure you read the Notification of Risks and any attachment accompanying this email, as they contain important information regarding your appointment(s).

Need to cancel or change your appointment date? Please respond to this email or contact the clinic at [phone number] with at least 24 business hours advance notice to avoid missed appointment fees.

Email Signature Disclaimer example: Virtual Care - Visit Email Invitation Consider including the following disclaimer in your virtual care invite emails or website pages:

DISCLAIMER: This virtual care visit, email invite and any attachment(s) is/are for authorized use by the intended recipient(s) only and must not be read, distributed, disclosed, used or copied by anyone else. If you are not the intended recipient, please notify the sender immediately, disconnect and delete any attachment(s). Patients may be re-directed to the clinic for an in-person visit at any time if the concern is deemed not appropriate for virtual care. Thank you.

Virtual Group Medical Visit Disclaimer example: Email Invitation Consider including the following disclaimer in your virtual care group medical visit invite (shared by Dr. Deni Hawley with permission): DISCLAIMER: By joining us online at the above link for this session, you are providing consent to participating in a group online visit, knowing that by the nature of a group visit, this is not an entirely anonymous session; however, you can choose to rename yourself, disable your video and audio, etc. to increase your privacy if you prefer. I will not disclose your specific confidential healthcare information in front of the group to preserve your privacy. You can withdraw your consent by leaving the group session at any time. No recordings are permitted. Please do not post this meeting link publicly online or on social media to protect our privacy. Thank you!

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Patient Consent Statements As a best practice, physicians should consider obtaining valid informed consent from patients prior to using videoconferencing or electronic communication to communicate potentially sensitive personal health information. This can be done during the first virtual care visit and can be applied to all subsequent sessions, provided that informed consent has been clearly documented in the patient chart.

Obtaining informed consent should involve the following components: ▪ explaining the appropriateness, limitations and privacy issues related to electronically communicating with the patient. ▪ explaining the risks related to unauthorized disclosure or interception of personal health information and steps they can take to help protect their information. ▪ discussing that care provided through video or audio cannot replace the need for physical examination or an in-person visit for some disorders or urgent problems and that alternative arrangements may need to be made. ▪ confirming that the patient understands the need to seek urgent care in an Emergency Department or Urgent Primary Care Centre as necessary.

How to Document Informed Consent in Your EMR Depending on your circumstance and the tools you are using, you may need to choose one of the following options on how to document patient consent: ▪ Canadian Medical Protective Association (CMPA) recommends the use of a signed informed consent form and provide a sample template in a Word doc, and PDF version. ▪ Consider paper vs. electronic forms. ▪ In some situations, obtaining written consent might be difficult – it is acceptable to obtain consent verbally and document consent in patient’s chart as long as it covers the details listed in the examples below.

Short statement to initiate a Virtual Care patient encounter, which has been approved by the CMPA: “Just like online shopping or email, Virtual Care has some inherent privacy and security risks that your health information may be intercepted or unintentionally disclosed. We want to make sure you understand this before we proceed. In order to improve privacy and confidentiality, you should also take steps to participate in this virtual care encounter in a private setting and should not use an employer’s or someone else’s computer/device as they may be able to access your information.

If you want more information, please check the link on our [website/confirmation email/etc.]. If it is determined you require a physical exam, you may still need to be assessed in person. You should also understand that virtual care is not a substitute for attending the Emergency Department if urgent care is needed. Are you ok to continue?”

Recording verbal consent in a patient’s chart. Copy and paste the following into the patient’s chart: Informed verbal consent was obtained from this patient to communicate and provide care using virtual and other telecommunications tools. This patient has been explained the risks related to unauthorized disclosure or interception of personal health information and steps they can take to help protect their information. We have discussed that care provided through video or audio communication cannot replace the need for physical examination or an in person visit for some disorders or urgent problems and patient understands the need to seek urgent care in an Emergency Department as necessary.

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Policies and Guidelines

Title Organization Overview

National Virtual Care Canada Infoway For physicians interested in learning more about virtual Resources During care, Canada Infoway has compiled a list of COVID-19 international, national and provincial resources. Virtual Care Playbook Royal College of This playbook was written to help Canadian physicians Physicians and Surgeons introduce virtual patient encounters (aka telemedicine) of Canada into their daily practices. It focuses on video visits, though phone calls and patient messaging are also categorized as virtual care. eCommunication CMPA High-level information from the CMPA regarding the use of eCommunications. including privacy considerations, protecting information, obtaining patient consent, and suitability. Public Health CMPA Overview of protection against medical-legal risk for Emergencies and physicians during emergencies that overload health Catastrophic Events resources. Telehealth CMPA Suite of articles outlining the CMPA’s principles of Information Package assistance, duties and responsibilities, and advice for physicians using telemedicine. Provincial Patient & Care Team Information Privacy and This policy describes how staff and Digital Security Standing providers can use digital communications in a Communications Committee consistent manner to communicate with Clients and Policy & Appendices other care Providers. The purpose is to establish specific requirements and processes to mitigate privacy and security risks associated with the use of digital communication.

Telemedicine College of Physicians and The role of the College is to regulate physicians, not Surgeons of British technology. Practice Standard includes advised Columbia practices for physicians providing medical care using telecommunications technologies. Medical Records, College of Physicians and Practice Standard outlining the use of emails and text Data Stewardship and Surgeons of British messages as they relate to a patient’s medical record. Confidentiality of Columbia Personal Health Information Care during COVID- BC College of Family Provides useful 1-pagers about caring for specific 19 Physicians populations, along with cultural safety & poverty tools. Virtual Health Policy PHSA This policy provides direction for the safe, effective, and strategic use of virtual health services across PHSA and supports staff in the use of Virtual Health at PHSA.

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VIRTUAL CARE

Frequently Asked Questions (FAQs) For frequently asked questions related to virtual care, please refer to the document ‘DTO Virtual Care FAQ for Physicians and MOAs’, which can be accessed here.

Will this Toolkit be updated? Yes, this Toolkit will continue to be updated on an as-needed basis, please check back here for the most recent version.

DTO Virtual Care Enablement Program Supporting the implementation of virtual care across the province with:

▪ Virtual Care Peer Support Network: a network of Physician and MOA Peer Mentors to support their colleagues, and/or help facilitate webinars and learning sessions. ▪ Virtual Care Learning Series: a set of video tutorials and real-life physician and MOA case studies on how to optimize the use of common virtual care tools. Visit the DTO YouTube page for info.

Additional Virtual Care Resources ▪ Virtual Care Quick Start Guide: An overview of the foundational processes, tools, and templates that a clinic should have to implement virtual care. ▪ Guide to E-faxing When Working Remotely: An overview of workflows and tools for physicians and MOAs who need to fax documents from outside the clinic. ▪ Virtual Care for Patients – FAQ & Troubleshooting Tips: Information to help patients prepare for virtual care visits. Designed for clinics to share with their patients as a resource guide. ▪ Video Remote Interpreting (VRI) for Sign Language: Instruction for family practice and specialists on how to book sign language interpreters to assist their patients during a video visit when necessary posted on PHSA website. ▪ Clinic Transition to Virtual Care Poster: - Editable/printable poster (MS Word) for clinics to notify patients that they are providing some of their care and visits virtually, either over the phone or video. English | Arabic | Chinese (simplified) | French | Hindi | Korean | Farsi | Punjabi | Spanish

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VIRTUAL CARE

Doctors Technology Office (DTO) is here to support you, please reach out with your virtual care questions to: 604 638-5841 [email protected] www.doctorsofbc.ca/doctors-technology-office

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